Clinical Review

How to prepare your patient for the many nuances of postpartum sexuality

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In the Term Breech Trial, the route of delivery had no impact on the resumption of intercourse, dyspareunia, or sexual satisfaction.23 Although the trial was randomized and controlled, it had many limitations that call its generalizability into question in regard to postpartum sexual dysfunction.

The National Institutes of Health (NIH) State-of-the-Science Conference on Cesarean Delivery on Maternal Request indicated that, by 6 months postpartum, there is no difference in sexual function based on the route of delivery.24 However, Lydon-Rochelle and colleagues used the SF-36 to assess reported general health status and found that women who had cesarean delivery or assisted vaginal delivery exhibited significantly poorer postpartum functional status than women who had spontaneous vaginal delivery in five areas at 7 weeks postpartum: physical functioning, mental health, general health perception, bodily pain, social functioning, and ability to perform daily activities.25 Women were more likely to be readmitted to the hospital and more likely to report fatigue during the first 2 months after cesarean delivery.9 It appears that women who undergo cesarean delivery have an elevated risk of nondyspareunia-related causes of sexual dysfunction. Any protective effect of cesarean on sexual function is limited to the early postnatal period and is related to the absence of perineal injury.18

How breastfeeding can affect sexual desire

Evidence is strong that breastfeeding reduces a woman’s sexual desire and the frequency of intercourse.1,5 A high level of prolactin suppresses ovarian production of estrogen, thereby reducing vaginal lubrication. Some women and their partner may identify this loss of lubrication as a lack of arousal. This type of vaginal dryness should be explained, and the use of a lubricant should be encouraged in breastfeeding women.

Nipple sensitivity may develop, making touching and foreplay uncomfortable in some women. One third to one half of mothers find breastfeeding to be an erotic experience, and one fourth feel guilty about this sexual excitement; others stop nursing or wean early due to these feelings.1,7 Women are often not educated about the relationship between the release of oxytocin, uterine contractions, milk ejection, sexual arousal, and orgasm; raising the subject can help to diminish any potential distress over this response.

Sleep disturbances from feeding on demand contribute to fatigue and exhaustion.

Many women may not realize that their loss of interest in sex may be because they are receiving sufficient physical contact or touching through their nurturing interactions with the baby. This may leave the partner feeling isolated and envious of the mother-baby relationship.

Couples should be encouraged to discuss these feelings to avoid misperceptions and to maintain the relationship dyad as a priority to prevent the development of relationship problems.

Women are reluctant to discuss sexual needs

The majority of women will discuss contraception with a health provider, but only 15% will voluntarily discuss their sexual needs or dysfunction.17 This finding is alarming given that, during the postpartum period, two of every three new mothers will experience at least one problem related to sexual function, including dyspareunia, decreased libido, difficulty achieving orgasm, and vaginal dryness.41 This lack of discussion with a health-care provider may be the result of several variables: incomplete knowledge on the part of the provider about what affects sexual function, poor training in the taking of an effective sexual history, and uneasiness on the part of the patient about discussing the issue.5,42

Postnatal depression takes a toll

Depressed mood and emotional lability in the postpartum period are negatively associated with sexual interest, enjoyment, coital activity, and perceived tenderness of the partner.7 Conversely, reduced sexual interest, desire and satisfaction; a lower frequency of intercourse; and later resumption of intercourse are associated with a higher number of psychiatric symptoms in the postpartum period.2 Between 10% and 15% of women experience postpartum depression (PPD).26 Depression has been associated with a decreased frequency and interest in sexual activity at 8 to 12 weeks postpartum.2,5

Chivers and colleagues assessed sexual functioning and sexual behavior in women with and without symptoms of PPD using the FSFI and EPDS. Although theirs was a small study, they found that women who had depressive symptoms also reported poorer functioning in regard to sexual arousal, orgasm, pain, lubrication, and sexual satisfaction.26 Morof and coworkers found that women who had PPD were less likely to have resumed intercourse by 6 months postpartum; they were also less likely to engage in other sexual activities.27

Role of pharmacotherapy

Many women are started on antidepressant medication near the time of delivery or during the immediate postpartum period. Often, serotonin reuptake inhibitors (SRIs) are used because there is minimal transmission of this class of medication through breast milk. However, the potential sexual side effects of these medications should be discussed because they are the agents most commonly associated with female sexual dysfunction.28

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